Medical Records Request

Virginia Spine Institute, PLC / DR.
11800 Sunrise Valley Drive
Suite 800
Reston, VA 20191
(p) 703-709-1114
(f) 703-709-1117

This information may include psychiatric, substance abuse, and HIV/AIDS information. I understand that I may cancel this request with written notification but that it will not affect any information released prior to notification of cancellation. I understand that the information used or disclosed may be subject to re‐disclosure by the person or class of persons or facility receiving it, and would then no longer be protected by federal regulations. I may receive a copy of this authorization for my records. Unless otherwise specified, this authorization expires 2 years from date signed.